Direct Peritoneal Resuscitation in Trauma Patients Results in Similar Rates of Intra-Abdominal Complications.

Background: Trauma patients undergoing damage control surgery (DCS) have a propensity for complicated abdominal closures and intra-abdominal complications. Studies show that management of open abdomens with direct peritoneal resuscitation (DPR) reduces intra-abdominal complications and accelerates abdominal closure. This novel study compares intra-abdominal complication rates and the effect of DPR initiation in patients who received DPR and those who did not. Patients and Methods: A retrospective chart review was performed on 120 patients who underwent DCS. Fifty patients were identified as DCS with DPR, and matched to 70 controls by gender, race, age, body mass index (BMI), past medical history, mechanism of trauma, and injury severity score. Results: The two groups of patients, those without DPR (-DPR) and those with DPR (+DPR), were similar in their characteristics. The +DPR group was more likely to have a mesh closure than the -DPR (14% and 3%; p = 0.022). The +DPR group took longer to have a final closure (3.5 ± 2.6 days vs. 2.5 ± 1.8; p = 0.020). Infection complications and mechanical failure of the closure technique were similar among the two groups. Timing of DPR initiation had no effect on closure type but did statistically increase the number of days to closure (initiation at first operation 2.8 ± 1.8 days vs. initiation at subsequent operations 6.0 ± 3.3 days; p ≤ 0.001). Conclusions: The use of DPR did not result in different outcomes in trauma patients. Therefore, traditional resuscitative measures for DCS may not be inferior to DCS with DPR. When choosing to use DPR, initiating it at the first operation could reduce the number of days to closure.

The Impact of Delays in Interfaculty Transfer on Outcomes in Elderly Trauma Patients.

BACKGROUND: Delay to definitive treatment is a significant and persistent challenge to trauma systems across the United States, especially in rural communities with limited resources. We hypothesized that elderly trauma patients with delay in transfer would have increased morbidity and mortality. This study evaluates the relationship between inter-facility transfer time and outcomes in elderly trauma patients, and the validity of the 4-hour dwell time as a performance improvement benchmark. METHODS: The National Trauma Registry and Emergency Medical Services Database were queried from January 2010 to January 2018. Inclusion criteria included age ≥65, blunt mechanism, and transfer from another facility. Correlation analysis was used to evaluate the association between clinical and demographic variables and transfer time. Multicollinearity was evaluated using the variance inflation factor. RESULTS: 1535 patients were identified. This cohort was further subdivided into 4 cohorts based on dwell time: 0-1.5 hours (n = 384), ≥1.5-1.9 hours (n = 379), 1.9-<2.5 hours (n = 383), and ≥2.5 hours (n = 388). Analysis revealed that shorter dwell time was associated with male gender (P = .0039), higher ISS (injury severity score) (P < .0001), lower RTS (revised trauma score) (P < .0001), higher pre-hospital arrest (P = .0066), lower initial GCS (Glasgow Coma Scale) (P = .0012), higher mortality, longer ICU, and ventilator length of stay (P < .0001). Longer dwell times were associated with discharge from the hospital to home or skilled nursing facility as well as lower mortality (P < .0001). DISCUSSION: Longer dwell time was inversely related to outcome. More severely injured patients were rapidly transferred. This represents a mature rural trauma system. In addition, dwell time should be scrutinized as a meaningful indicator within a performance improvement program.

Where to Draw the Line for Intracranial Hypertension; Opening Pressures and Mortality.

BACKGROUND: Intracranial pressure (ICP) monitoring and treatment is a mainstay of severe TBI management but the relationship between intracranial opening pressure (OP) and outcomes has not been well established. The purpose of our study was to assess the relationship between OP and outcomes in severe TBI patients, with a focus on in-hospital mortality. METHODS: Adult blunt TBI patients with ICP monitoring between 2007 and 2017 were evaluated using sequential multivariable binary logistic modeling. Generalized additive model (GAM) was used to evaluate the relationship between OP and death. Odds ratio (OR) and 95% confidence interval (CI) were calculated for measures of strength of association and precision. RESULTS: A total of 182 patients were identified, with 61 (33.5%) having OP >20 mmHG (overall mean ± OP = 19.4 ± 17.8 mmHG). Forty-eight percent, 9% and 8% of patients were discharged to rehabilitation, skilled nursing institution, and home, respectively. Thirty-five percent died in the hospital. A linear relationship was found between OP and log-odds of mortality. OP (OR = 1.07; 95% CI = 1.04-1.11), age (OR = 1.05;95%CI = 1.02-1.07), and injury severity score (ISS) (OR = 1.06; 95% CI = 1.02-1.10) were independently associated with increased odds of death while adjusting for sex, race, and year. DISCUSSION: Elevated opening pressure is strongly predictive of death in severe TBI. Age and ISS are independent predictors of mortality regardless of OP. These results suggest that maintaining low levels of ICP should result in decreased mortality in severe TBI patients. The patient's age and ISS should be considered in the decision-making processes related to ICP utilization and management.

Assessing Risk for Mortality in Trauma: The Value of Admission Hemoglobin A1c.

BACKGROUND: Recent efforts have been made to identify admission characteristics of trauma patients that are associated with increased risk of mortality. Contemporary literature has established an increased risk of mortality with admission hyperglycemia. However, the effects of longstanding hyperglycemia, as surrogated by hemoglobin A1c (HbA1c), has not been studied. METHODS: A prospective trauma database was retrospectively reviewed identifying patients with collected HbA1c at admission. Three cohorts were defined by HbA1c: normal (N), <5.7; prediabetic (PD) 5.7-6.5; and diabetic (D) >6.5. Regression models were used to evaluate the risk of increased hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and mortality. Relative risk (RR) and 95% CI are provided as measures of significance. RESULTS: A total of 2978 patients were included in the analysis (N: n = 1895, PD: n = 744, and D: n = 339). The D cohort was more likely to be older, female, obese, suffered blunt trauma, and triaged at the highest activation acuity level (P < .0001). Mean injury severity score (ISS) was similar between groups. The D group was more likely to have longer ICU-LOS (RR 1.5; 95% CI 1.10-2.07) and ventilator days (RR 1.52; 95% CI 1.03-2.26) than the N group. Relative to the N group, the risk of mortality was 50% higher in the PD (RR 1.49; 95% CI 1.17-1.90) and in the D cohorts (RR 1.50; 95% CI 1.03-2.18). DISCUSSION: Trauma patients with an elevated admission HbA1c have a significantly higher risk of mortality regardless of their history of diabetes. These data add to the body of literature that documents the untoward effect of hyperglycemia on the trauma patient.

Infectious complications in combined colon resection and ablation of colorectal liver metastases.

BACKGROUND: The multifactorial incidence of infectious complications carries considerable consequences for patients undergoing more extensive surgery with intent to cure metastatic colorectal cancer. Advances in ablation techniques have emerged as an efficacious method in regional control for liver metastasis from colorectal cancer; however, the degree of increased risk of infectious complications when ablation is performed in combination with colon resection has not been defined. METHODS: An analysis of a single institution's prospective database from August 1998 to December 2012 was performed for patients undergoing colon resection. Patients were stratified into a colon resection combined with either microwave ablation (MWA) or radiofrequency ablation (RFA) compared to a colon resection only group. Variables included baseline clinicopathologic data, type of operation, complication grade, and infectious outcome. Fisher exact test, Student t test, and analysis of variance were used to detect significance levels of P values less than .05. RESULTS: A total of 132 patients with colon cancer of various origins were identified. The group of colon resection combined with RFA and/or MWA was 53 patients (34 male:19 female) and was compared to a matched group of 79 patients (40 male:39 female) who underwent colon resection alone. Median age (58 vs 60 years; P = .209), complication rate (60.7% vs 62.5%; P = .722), infection rate (28.7% vs 35.4%; P = 1.0), mean blood loss (352.7 vs 468.4 mL; P = .452), mean blood transfused (1.36 vs .76 U; P = .247), and receipt of neoadjuvant chemotherapy (47.1% vs 51.85%; P = .724) were all similar between the ablation group and colon only group, respectively. Transfusion rate was higher in the ablation group (39.6% vs 18.9%; P = .016). Overall complication rate was 60.6%, with 32.6% infections. One mortality was observed in each group. High-grade (grade, III to V) complications (35.8% vs 18.9%; P = .0112) and liver-specific complications (n = 4; P = .024) were significantly increased in the combined ablation group. CONCLUSIONS: Combining MWA or RFA techniques with colon resection for liver metastasis appears to have similar infectious and overall complication rates when compared to performing an isolated resection of the primary colon cancer alone, although there may be a higher degree of complication seen in the more aggressive approach for curative intent in patients with colorectal liver metastasis.